“NO EXCUSE” said posters on the platforms of the London Underground a few years back. The blackened eyes of a woman stared at the public. Another campaign against domestic violence, Londoners may have first thought seeing the poster. On closer look it gave a shocking statistic “A London ambulance crewmember is assaulted once every day.”

Those on the frontlines of medical care such as EMT’s, ER personnel and mental health workers can be the Rodney Dangerfields of medicine. Often they “don’t get no respect,” as the late comedian would say tugging on his tie (or perhaps stethoscope?) . Jokes aside, EMS personnel have been hit, kicked, stabbed, shot, stoned, spit upon and received racial slurs all while trying to help, often those doing the in assaulting are the ones needing the assisting.

It is puzzling. There may be no excuse and no respect but also no logic. Even the most self centered and violent individual has no reason to hurt their caregiver. But on many calls with substance abuse or intense emotion, logic is often the first casualty.

And EMT’s can be the next casualties. Last July, Tami Stephen of Madison County, NC EMS was called to assist an elderly man at a country club. The patient shot her in the chest with a .22 caliber pistol. She survived. Marsha Rainey and Bradley Maxwell of Jasper, Indiana were killed in a double homicide at their station. A similar fate met Katherine Malone and Tye Brown of the Metropolitan Ambulance Services Trust of Kansas City, Missouri shot by someone who snuck into the station. Anthony Pirraglia of Charleston, SC was shot and killed by an man he offered to help after a traffic accident. Lieutenant Brenda Cowan and Jim Sandford, paramedics for the Lexington KY fire department, received a call for help at a domestic violence call in February, 2004. The two were shot, killing Cowan. The suspect was considered incompetent to stand trial.

Dr Brian Maguire, professor of EMS and occupational risks at the University of Maryland, Baltimore County, has studied the problem. He was a New York City paramedic for twenty years. “I worked virtually every neighborhood and I was never assaulted but many of my friends were,” he said. After getting further into academia he was surprised there was no research into this problem. “We know it is a significant problem,” he said, but adds questions still outnumber the answers.

He compared this issue to the health care provider finding someone with a fast pulse rate but not knowing what caused it. “Was the person is having a heart attack, was shot or just ran a marathon,” he said. “We know there’s a problem but we have to know how to treat it. ” Maguire said.

His research included assaults with “indication of intent to harm someone,” he said. “If the patient was having a seizure and punched the EMT that was not considered an assault.” Maguire had seen a few patterns show up in his studies. Some assaults may come from a family member of the patient. They may perceive EMS as too slow in getting to the emergency or not moving fast enough when they get there. There are patients who are upset and lash out at EMS. Another group are addicts who look at an ambulance as a source for drugs.

Health professionals, from the chief surgeon to orderlies, are taught to value teamwork. The team together is greater than the sum of its parts. But the mob can be worse than the sum of its parts. It acts while the individual thinks. Aaron Frisch and Kathy Zeller, paramedics for Toledo, Ohio’s Life Squad, experienced this.

In October of 2005, neo Nazis marched in a predominately African American neighborhood angering residents. “I’d be upset too if they were marching in my neighborhood,” Frisch said in a phone interview from his station.

“There was a Life Squad staged in case things got a little rough,” he said. After the marching was done their unit was sent to a staging area. “We saw a crowd in the intersection. A civilian flagged us down and said ‘you don’t want to go down there.” Zeller said they found out later the mob had already destroyed a gas station.

The two had their instructions to head to the staging location, but a miscommunication meant they did not get the message to avoid this area near Central and Mulberry, Zeller said. They couldn’t believe it when a rock hit the window. “It was one kid throwing rocks and then it snowballed. People in the crowd were telling them not to do it,” she said. Then more rocks came through the side glass. One rock hit Frisch on the elbow and another hit Zeller in the head. Frisch backed up quick enough to get out before more serious injuries. Both soon recovered and are back on the job.

What caused this violence? “My personal opinion is now days people are not being taught personal responsibility. It’s all about yourself. It doesn’t matter if it hurts others,” Frisch said. The mob was predominately black, angered by white supremacists and both paramedics were white, but Zeller does not believe they were targeted because of their race. “They couldn’t have seen Aaron and I.. If my partner had been black it would not have made a difference,” she said. At the court house, Zeller remembered a boy of about seventeen caught throwing rocks who did not even know about the march. Frisch saw a thirteen-year-old suspect from the riots with his mother, who was also accused of throwing rocks at people alongside her son.

So what is mob violence? Rather than a psychologist studying the matter from the outside, writer Bill Buford wanted to find out from the inside and spent several years joining fans of the British soccer team Manchester United. He found himself caught up in a few soccer melee’s and brings the reader into the mentality of mob violence in his book AMONG THE THUGS. (W.W. Norton and Company, 1991)

Buford said the group had a term for that time when things descended into chaos -”going off”. During a fracas in Turin, Italy, he saw his group beating people, breaking windows, urinating in fountains and looting. During the height of the violence he remembered a man named Sammy “He was repeating the phrase ‘it’s going off, it’s going off.’ Everyone around him was excited. It was an excitement. More like ecstasy. There was an intense energy about it; it was impossible not to feel some of the thrill. Somebody near me said that he was happy. He said that he was very, very happy, that he could not remember ever being so happy.” (Page 87 and 88 ) Reflecting on it later he added more thoughts on the time “it goes off.” “They talk about the crack, the buzz, and the fix. About having to have it of being unable to forget it- ever. Violence is one of the most intensely lived experiences and for those capable of giving themselves over to it is one of the most intense pleasures. I felt as the group had passed over a metaphorical cliff and that I had literally become weightless. what was it like for me? An experience of absolute completeness.” (page 204-205)

“Excuse me, sir, I’m a paramedic. We just need to take your blood pressure and see if everything is okay.”

Crimes often bring EMS, but when the crimes are in progress, that can bring tragedy. In August, 1966 a sniper at the University of Texas tower in Austin shot ambulance driver (this was before EMT’s and paramedics) Morris Hohman in the leg. He recovered. A March, 2000 incident sent Memphis, Tennessee firefighters William Blakemore and Javier Lerma to a fire at a home where the owner killed them both, plus his wife and a sheriffs deputy. A home video shows the gunman walking around the yard, shotgun in hand, near paramedics working on firefighter Lerma. “Initially I was so wrapped up in what was going on, but looking back I probably could have been shot. It was probably pretty stupid,” THE COMMERCIAL APPEAL reported one of the paramedics, Mark Eskew, saying in the trial of gunman Frederick Williams.

And therein lies the problem. The EMT is looking for little things like the pulse, the muffled sounds of heart beats and qualities of respiration. If the EMT is new they are also remembering not to put the EKG leads on backwards. “People tend to focus in on the patient and don’t pay attention to their surroundings. It comes with experience,” Glenn Faught, director of the Emergency Medical Services department at Southwest Tennessee Community College in Memphis, said. Early in his career he was called to a home and a man started shooting. “I was very inexperienced and had no idea that people would shoot at EMS,” he says. In two other cases his life was threatened by the patient and a parent of a patient. “They were drug related. Especially PCP. PCP will get you killed.”

Faught adds attitude is another way to avoid violence. “It’s how you portray yourself to the person who may become violent. There is a false perspective among EMS you are a respected authority,” he says. “The people who do not respect the police will not respect you.”

Dispatchers try to keep crime and EMS apart said Eugene Gibb, senior police service representative II, who works with Los Angeles Police Department Communications Division. He has been working in dispatch for 22 years. Calls for help in Los Angeles go to the police primary answering point and then are triaged to the appropriate department. “If it’s a medical emergency or a shooting or stabbing we find out what’s going on,” he said. The police can conference in with the fire department to hear if a crime was involved in the EMS call or anything else that may need police assistance. “We create an incident and code it. While the fire department is interviewing, we get an idea of what is going on and when the fire department is through with their interview then we get more information. Protocols on how we dispatch the call depend on elements given to us by the caller,” he said. EMS is advised to stage or to head directly to the scene. “Fire response a lot of times can get there quicker than police because they may be tied up on other calls,” he said.

Many states have laws that upgrade assaults on EMS personnel from misdemeanors to felonies. After the murder of a doctor in Florida for providing abortions in March, 1993, the federal government made attacks against abortion or abortion alternative facilities and personnel a federal offense. The FBI investigates such incidents but other medical assaults are generally a state matter.

“We should have tougher laws against assaults and enforce them,” said Skip Straus who started as a paramedic in 1973, working some of the mean streets of Houston, Texas and now is working in North Harris County, Texas. When he started wearing a bulletproof vest on the job he was “ribbed endlessly but that’s okay,” he said. He said violence was an issue in 1973 just as it is today. Another problem he gives that is attacks are not followed up by their agencies, but just become the stuff of stories. “I would like employers to admit to the problem. A lot of agencies sweep it under the rug.”

A danger he sees is what he calls the “machismo” attitude of “Nothing is going to happen to me. I hear it on the radio all the time ‘option to stage,’ he said but adds many do not. “Stage. Even then keep your eyes and ears open,” he advises.

Maguire readily admits that answers to avoid being attacked are in short supply, but he has found some tips. “We need appropriate recommendations not just reactionary ones,” he said. He disagreed with Strauss’ recommendation that a bulletproof vest is good protection. Data from past assaults showed no evidence these people would have been better off with the device and perhaps it may cause the rescuer to take risks he or she may not have taken without the protection.

“Stay healthy,” Maguire recommends to EMT’s. “In case of trouble if we have to move fast we can move fast,” he said. And he added the EMT must be vigilant. “Be aware this is a dangerous occupation. Not everyone is waiting with open arms when we arrive.” But a safe situation can turn dangerous. “I think a case can be made for self defense training,” Maguire said.

Aaron Frisch from the Toledo riots said he will heed warnings like the one they received before the attack and avoid suspicious crowds. His partner, Kathy Zeller, recommends training for emergency drivers on what to do and how to drive in a mob situation.

It seems easy for the EMT to become discouraged when dealing with an abusive patient. “I studied hard for two years to make a difference. Right now I could be at the movies, fishing, sleeping or anywhere else but I’m out here working hard to save you. A thank you would be nice but if you can’t do that can you at least not hit me?!?!” is probably what any assaulted EMT would love to scream into the face of an abusive patient. What good is it to be a caregiver to someone who, well, doesn’t care? Is it really worth it?

Straus is also an emergency chaplain to several EMS agencies in the area. He is as much a minister as he is a paramedic. “It IS worth it because you did help them,” said Straus, he sees scriptures as pointing out this strange paradox. “The Bible tells us that we are going to suffer for the good that we do.” Straus is a man of faith, but also he is a practical. “Understand violence is there and watch your back and your partner’s back.”

Drugs. Mental Illness. Anger. Most medical violence is generally spontaneous but it can also be calculated. At a Nashville, Tennessee seminar for EMT’s and paramedics, Jackson, Tennessee physician Michael Revelle who was stationed in Iraq with the 101st Airborne, said medical violence there is often organized and deliberate. The bounty to kidnap American medical personnel is actually higher than for a commanding officer. He showed a picture of an armored personnel carrier with a large red cross on the side. The army quickly stopped using it. “That giant red cross looks like a target to insurgents.”

FOR MORE INFORMATION:Books:AMONG THE THUGS by Bill Buford, W W Norton Publishers. A study on mob violence from someone who has been thereA SNIPER IN THE TOWER: THE CHARLES WHITMAN MURDERS by Gary Lavergne, University of North Texas Press. A true crime book on the 1966 University of Texas sniper.WHEN VIOLENCE ERUPTS: A SURVIVAL GUIDE FOR EMERGENCY RESPONDERS by Dennis Krebs, AAOS PublishersArticles: